Gynecological health and uptake of gynecological care after domestic or sexual violence: a qualitative study in an emergency shelter

Background Domestic and sexual violence have been linked to adverse gynecological and obstetric outcomes. Survivors often find it difficult to verbalize such violence due to feelings of shame and guilt. Vulnerable or socially excluded women are frequently excluded from research, particularly qualitative studies on violence. This study aimed to characterize the perceived impact of domestic or sexual violence on the gynecological health and follow-up among women with complex social situations. Methods We analyzed the data following inductive thematic analysis methods. Results Between April 2022 and January 2023, we conducted 25 semi-structured interviews, lasting on average 90 min (range: 45–180), with women aged between 19 and 52, recruited in an emergency shelter in the Paris area. The women described physical and psychological violence mainly in the domestic sphere, their altered gynecological and mental health and their perception of gynecological care. The levels of uptake of gynecological care were related to the characteristics of the violence and their consequences. The description of gynecological examination was close to the description of coerced marital sexuality which was not considered to be sexual violence. Gynecological examination, likely to trigger embarrassment and discomfort, was always perceived to be necessary and justified, and consent was implied. Conclusion This study can help question the appropriateness of professional practices related to the prevention of violence against women and gynecological examination practices. Any gynecological examination should be carried out within the framework of an equal relationship between caregiver and patient, for the general population and for women with a history of violence. It participates in preventing violence in the context of care, and more widely, in preventing violence against women. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-024-03112-0.


Introduction
Since 2017, the international Metoo movement has contributed to freeing women's voices about sexual violence [1][2][3].However, domestic or sexual violence is still difficult to verbalize for survivors and associated with a lack of social and emotional support [4][5][6][7].A controlled trial in the US showed that following sexual assault, survivors were more reduced to silence and stigmatized than after physical violence [8].Several studies showed a link between a history of domestic or sexual violence and the occurrence of obstetric and gynecological symptoms or diseases that could encourage women to consult a health professional.Indeed, pain -pelvic pain, dysmenorrhea and dyspareunia -uterine bleeding, vaginismus, and endometriosis were increased among women reporting violence during childhood or adulthood compared to those who did not report such violence [9][10][11][12][13].A majority of women survivors of violence who attend a consultation do not mention the violence to the caregiver, possibly because of the shame and guilt experienced after this violence [1,14].
Several quantitative and qualitative studies showed the association between a history of domestic or sexual violence and a negative experience of pelvic examination [15][16][17][18][19][20][21][22].Women with a history of domestic or sexual violence reported discomfort, embarrassment, shame, or an increased pain experienced during the gynecological examination compared to those who had not been subject to violence [15][16][17][18][19][20][21][22].In 2022, we conducted a qualitative study that identified differences regarding the frequency of uptake of gynecological care for women surveyed by a feminist organization tackling sexual violence [23].In that study, the differences in the uptake of gynecological care were associated to the characteristics of violence and its perceived effect on gynecological health.The participants in this study were all socially and professionally integrated.The study did not include any woman subject to complex social pathways [23].Such women are often excluded from research, specifically qualitative studies about violence.The aim of this study was to characterize the perception of the impact of domestic or sexual violence on gynecological health and gynecological care among women likely to present with a vulnerable situation or facing social exclusion.

Methods
The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were followed [24].

Ethical considerations
The study was granted ethical approval from the ethical and research committee of Paris University (reference N°2021-82, October 12th, 2021).Informed consent was obtained from all individual participants included in the study and participants were assured of the confidential nature of the information collected.

Study population
Semi-structured interviews were conducted with women recruited in an emergency shelter in the greater Paris area that welcomes women who have escaped violence, for a maximum of two months.Participants were approached using non-probability convenience and snowball sampling.Interviews were not conducted with women who presented acute anxiety, agitation, restlessness or confusion.When the research interview would alter psychic health by visibly reviving the trauma (flashbacks, acute anxiety), the interview was not initiated or continued.Interviews were not conducted with woman who had therapeutic expectations from the research interview, such as an exclusive need for psychological or gynecological care.

Data collection
The individual face-to-face interviews lasted on average 90 minutes (range: 45-180) and were conducted by one of us (EI, midwife and PhD student), in French.Up to three pre-interviews were needed to establish a trusting relationship between the researcher and the participant.Interviews were audio-recorded and transcribed verbatim.At the beginning of the interview, some questions were asked so that the researcher could become familiar with the participants, gain their trust and create a safe atmosphere.Before the interview, the participants' consent was obtained for participation and recording of the interview.Information was collected on their age, country of birth, level of education, and occupation.A semi-structured guide covering gynecological health, gynecological follow-up and domestic and sexual violence was used to shape interviews.Some examples of interview questions were as follows: "Could you tell me about your gynecological health?","What might lead you to consult a gynecologist or a midwife?", "What is your perception of gynecological examination?"Could you tell me what brought you here?"(The interview guide is presented in Supplementary file 1).
Several listenings were needed to check the accuracy of the transcription.The transcribed data were compared with the field notes-e.g., non-verbal behavior was carefully transcribed during the interview-to ensure the completeness of the data collected.After verifying the accuracy of the transcription, recordings were destroyed.The data collection was ongoing until data saturation.The women interviewed were asked to identify themselves with a pseudonym.

Data analysis
We analyzed the data following inductive thematic analysis methods, using NVIVO Version 10 [25,26].The recorded interviews were first carefully listened to and then transcribed verbatim.During the first stage, words, sentences or paragraphs of text were coded and combinations were formed using an inductive process.During the second phase, the final 5 interviews were used to confirm theoretical saturation across the data set, and to finalize the coding framework.During the third phase, we assembled the codes into potential themes and gathered all relevant data for each theme, checking the relevance of the themes in relation to the coded extract and the dataset as a whole.An example of a coded verbatim divided into themes and sub-themes is provided in Supplementary file 2. The reliability of the research was enhanced by the similarity of the results obtained individually, then cross-referenced by three authors (EI, JPM, PC), over the three stages, to limit subjectivity in data interpretation.The participants were involved in the research process to verify data consistency.Extracts of their data were shown in order to obtain their feedback, while taking care not to confront them with a verbatim report that was difficult to listen to or to read.
The professional backgrounds of the four authors, combining experience in sexual and reproductive health (EI, JPM, IB) and forensic medicine (PC), enriched data analysis, while ensuring that the sense of the participants' words was not lost.

Results
Between April 2022 and January 2023, 25 semi-structured interviews were conducted with women aged 19 to 52.Five women who had consented to participate in the study were lost to follow-up.The participants were in a vulnerable social situation or in a situation of social migration, had little or no academic qualification, or had a degree that was not acknowledged in France (Table 1).For some, speaking in French or English was difficult when it was not their mother-tongue.However, living in a shelter with other women helped them improve their French.Although an interpreter could have been called on if communication proved impossible, it was actually not needed.At the time of the interview, most of them declared having access to health insurance that ensured that their gynecological and obstetric care be state-funded.The codes, divided into themes and sub-themes are presented in the thematic tree (Fig. 1).

Theme 1: perception of domestic sexual violence
Women described a history of physical and psychological violence mainly in the domestic sphere.Violence was often associated to economic dependency, making leaving the home difficult.The last episode of violence was recent, and had taken place from a few days to a few weeks before the research interview.It was considered by the women to have been sufficiently serious to justify being housed urgently outside the marital home.They described the violence by closeantly referring to death.We argued and he grabbed my hair (…).We lived in a duplex, he threw me down the stairs.He hit me.To this day I still wonder 'How am I still alive?How am I still alive?' .The neighbours heard.They heard every time but they did nothing, they were afraid of him.

My neighbour told me 'I heard, I thought of calling the police' . I told her she should have. What if I had died? (Ana, 33 years old, unemployed)
When questioned about sexual violence in the domestic sphere, they denied its existence.However, as they Fig. 1 Thematic tree were asked to qualify their intimate and sexual life, they described it as forced or coerced, without referring to it as sexual violence.Following an event of physical domestic violence, sexual intercourse was perceived as what they referred to as 'reconciliation' and was considered more tolerable than physical violence, even when it was not desired.While they did not name sexual violence in the domestic sphere, the participants described a chaotic and deprived childhood with violence, including sexual violence.
I was abused sexually when I was little.I am incapable of knowing when it started but in my first memories, I was 4 or 5.It was the son of my mother's partner.Then, we were reported to child protection services but only for physical violence.(Anaïs, 26 years old, unemployed) There were repeated rapes by my step-father.I don't know when it started but I must have been very little.Since I was little, I did not know that it was not normal, the rapes (…) I thought it was a game, so I said nothing.When I turned 10, I began asking myself questions 'Is it normal?Is he allowed?' (…) No, it was not normal.I began to understand that it was bad.I started being aggressive, almost unbearable.I began my teenage crisis earlier than planned.Even my grandparents did not recognise me, as with them I was usually kind and peaceful (…).Then, I became aggressive even with them.(Louna, 31 years old, unemployed)

Theme 2: deteriorating mental and gynecological health
The participants presented gynecological symptomspelvic pain, dyspareunia, dysmenorrhea, vulvodynia, bleeding, menstrual cycle disorders, infections-and psychological symptoms-anxiety, depression, eating disorders, addictions, ideation and suicidal behaviors, mental reminiscence.Pain (menstrual pain or dyspareunia) was a symptom that was often cited, associated to acknowledged sexual violence or to a sexuality described as unwanted, coerced or forced.
Gynecological symptoms The integrity of the hymen, considered by women to be a proof of virginity, was raised when they reported the impact of the violence, as well as when they explained the motivation to access medical care, even a long time after the violence.Limited financial resources associated with social vulnerability contributed to the decision not to seek gynecological care.In addition, factors such as low self-esteem and an inability to cope with the consequences of a diagnosis dissuaded women from seeking care.They did not wish to add negative events to an already chaotic and complex life.The description of a gynecological examination was close to that of coerced marital sexuality which was not considered to be sexual violence.The gynecological examination, likely to trigger discomfort was always perceived to be necessary and justified, and consent was implied.

Actually, I did not (…) uh (…) I left (…) actually, I had an appointment with a gynecologist but did not go (…) I let it go. (Tears
When the physicians considered the gynecological examination necessary, their consent or approbation was not required. He

Discussion
The women reported physical and psychological violence mainly in the domestic sphere.They also described an altered gynecological and mental health and their perception of gynecological care.The levels of uptake of gynecological care were related to the characteristics of the violence and their consequences.When questioned about domestic sexual violence, they denied its existence.However, as they were asked to qualify their intimate and sexual life, they described it as forced or coerced, without referring to it as sexual violence.The description of gynecological examination was close to the description of coerced marital sexuality, which was not considered to be sexual violence.Gynecological examination, likely to trigger embarrassment and discomfort, was always perceived to be necessary and justified, and consent was implied.Their husbands' sexual needs or the medical practitioner's needs to perform a gynecological examination outweighed their own needs and therefore did not require their approval or consent.While the perception of the impact of violence on gynecological health is comparable between women surveyed by a feminist organization (FO) [23] and those recruited in an mergency shelter (ES), there was a difference in the perception of domestic sexual violence and perception of violence during gynecological care.Thus, FO women reported domestic sexual violence while ES women did not consider forced sexuality in the context of physical and psychological violence as sexual violence.Their sexuality aimed at addressing their partner's needs rather than their own emotional and sexual needs.The FO women also reported sexual violence in gynecological care [23], as previously shown by a Swedish study establishing that women with a history of violence during childhood were more likely to perceive care as violent [27].Conversely, ES women described unease and discomfort, without referring to violence in gynecological care, which was described as useful and justified, which means that consent was implied.
We can assume that the perception of domestic sexual violence and violence in gynecological care is likely to vary depending on the timing of the violence, its repeated nature, and emotional, social and psychological support.This perception can also vary depending on education (egalitarian or stereotyped) and on a sense of belonging to a feminist culture as opposed to exclusive references to a patriarchal model.
Taking gynecological care or not can result from a choice, which contrasts with the impossibility of expressing free choices when life is controlled by domestic and sexual violence.
Data regarding mental health in our study corroborate the findings of several studies showing the link between domestic or sexual violence and disorders or symptoms such as depression, particularly postnatal depression [28][29][30][31][32], posttraumatic stress disorder [29][30][31], addictive behaviors [33], eating disorders [31,34] and suicidality [31,35].The women interviewed in the present study regretted a lack of communication during the medical interview or a minimization, by health professionals, of the gynecological symptoms attributed to the violence, similarly to the women recruited by an FO [23].Our results on the levels of gynecological care strengthen the findings of qualitative studies identifying the differences in levels of uptake of gynecological care in connection with the characteristics of the violence and their perceived effect on gynecological health [23,36,37].
Our study can help question the appropriateness of professional practices related to the prevention of violence against women.In France, the National Health Authority recommended screening for domestic violence [38], as did international learned societies [39,40].However, there is no French medical recommendation on screening for a history of sexual violence in adult women, as opposed to other countries like the US [41,42].This study also led to question the appropriateness of practices around gynecological examination.In the US, the UK and Australia, the indications of pelvic examinations are well defined [43][44][45].Any gynecological examination should be carried out within the framework of an equal relationship between caregiver and patient, as well among women with a history of violence as in the general population.

Strengths and weaknesses
Recruitment via organizations enabled to interview people in a neutral research setting rather than in the context of care and led to integrating women with difficult seek to gynecological care.Participants talked about their perception of the impact of violence on their health and gynecological care, topics which are usually ignored in care contexts, due to their association with guilt and shame.The study helped interview women with complex social pathways, usually excluded from any research on violence.We explored public health concerns regarding gynecological follow-up after domestic and sexual violence, including the interactions between biological, psychological, social and environmental factors.
Therefore, we cannot generalise the validity of the conclusions of this study to the general adult female population living in France.Future research is needed to understand, on the one hand, the uptake of gynecological care violence and, on the other hand, the social and psychological factors associated with the experience of domestic sexual violence and gynecological violence.

Conclusions
Patients' adherence to a medical act, such as a pelvic examination, is a critical element of the healthcare relationship, based on a clear understanding of the reasons for the examination and the conditions under which it will be performed.It contributes to avoid retraumatization, participates in preventing violence in the context of care, and more widely, in preventing violence against women.

Table 1
Degree, profession and length of residence in France

Nick Name Degree Occupation Length of residence in France if born abroad Age
So, he put his sex in my mouth.I said I did not like it but he kept going.And sometimes when he couldn't put it in my mouth, he put in my bottom.I told him to stop but he did not stop.(Tears)(Nora,25 years old, unemployed)